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Public health measures and strategies to limit the spread of COVID-19: antigen testing
Health Information and Quality Authority
Public health measures and strategies to
limit the spread of COVID-19: an
international review
Antigen testing in asymptomatic
individuals in community settings
Submitted to NPHET: 10 February 2021
Published: 24 February 2021
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Public health measures and strategies to limit the spread of COVID-19: antigen testing
Health Information and Quality Authority
Version history
Version Date Specific updates
V1.0 24 November 2020 Provided to the National Public Health
Emergency Team (NPHET) for information.
V2.0 1 December 2020 Updated and provided to NPHET for
information.
Included an additional table (Table 1) to
summarise the recent changes in current
public health measures.
Updated the epidemiological data to the
latest available data from the European
Centre for Disease Prevention and
Control (ECDC).
Included information on the proposed
plans for mass testing in Austria.
V3.0 8 December 2020 Updated and provided to NPHET for
information.
Updated the epidemiological data to the
latest available data from the European
Centre for Disease Prevention and
Control (ECDC).
V4.0 15 December 2020 Updated and provided to NPHET for
information.
Updated the epidemiological data to the
latest available data from the European
Centre for Disease Prevention and
Control (ECDC).
V5.0 23 December 2020 Reduced version of report created with updated
public health measures on education only.
V6.0 06 January 2021 Included information on the current
epidemiological situation in each country.
Updated the education public health
measures only.
Page 2 of 44Public health measures and strategies to limit the spread of COVID-19: antigen testing
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V7.0 3 February 2021 Included updated information on antigen
testing in asymptomatic individuals in
community settings only.
V8.0 10 February 2021 Included information on the current
epidemiological situation in each country.
Included updated information on antigen
testing in asymptomatic individuals in
community settings only.
Page 3 of 44Public health measures and strategies to limit the spread of COVID-19: antigen testing
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About the Health Information and Quality Authority
The Health Information and Quality Authority (HIQA) is an independent statutory
authority established to promote safety and quality in the provision of health and
social care services for the benefit of the health and welfare of the public.
HIQA’s mandate to date extends across a wide range of public, private and voluntary
sector services. Reporting to the Minister for Health and engaging with the Minister
for Children, Equality, Disability, Integration and Youth, HIQA has responsibility for
the following:
Setting standards for health and social care services — Developing
person-centred standards and guidance, based on evidence and international
best practice, for health and social care services in Ireland.
Regulating social care services — The Chief Inspector within HIQA is
responsible for registering and inspecting residential services for older people
and people with a disability, and children’s special care units.
Regulating health services — Regulating medical exposure to ionising
radiation.
Monitoring services — Monitoring the safety and quality of health services
and children’s social services, and investigating as necessary serious concerns
about the health and welfare of people who use these services.
Health technology assessment — Evaluating the clinical and cost-
effectiveness of health programmes, policies, medicines, medical equipment,
diagnostic and surgical techniques, health promotion and protection activities,
and providing advice to enable the best use of resources and the best
outcomes for people who use our health service.
Health information — Advising on the efficient and secure collection and
sharing of health information, setting standards, evaluating information
resources and publishing information on the delivery and performance of
Ireland’s health and social care services.
National Care Experience Programme — Carrying out national service-
user experience surveys across a range of health services, in conjunction with
the Department of Health and the HSE.
Page 4 of 44Public health measures and strategies to limit the spread of COVID-19: antigen testing
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Contents
Version history ..................................................................................................... 2
About the Health Information and Quality Authority ............................................... 4
Key points ........................................................................................................... 6
1 Background ................................................................................................... 8
2 Methods ........................................................................................................ 8
3 Findings ...................................................................................................... 10
3.1 Summary epidemiological data ............................................................... 10
3.2 Antigen testing in asymptomatic individuals in community settings ........... 14
4 Discussion ................................................................................................... 24
References ........................................................................................................ 29
Appendix ........................................................................................................... 34
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Key points
As of 8 February, the 14-day incidence rate of new cases in Ireland stood at
313.4 per 100,000 population. Of the 21 included countries, the rate was
highest in Portugal (1,224.0), Czechia (909.5), and Spain (846.3).
Thirteen of 21 countries had seen a decrease in the number of new COVID-
19 cases recorded over the previous seven days, nine of which had been in
excess of a 10% decrease including Ireland (17.6%).
For week four in January, weekly testing (RT-PCR and antigen tests) per
100,000 population ranged from 741.6 in Poland to 13,409.2 in Denmark,
with Ireland’s rate at 2,794.8 per 100,000.
In a number of countries, the weekly positivity rate (RT-PCR and antigen
tests) was trending downwards with the following exceptions: Austria,
Finland, Greece, Malta, the Netherlands, Portugal and Slovakia.
Antigen testing of asymptomatic individuals in community settings was
reported in 22 of the 24 jurisdictions reviewed with the exception of Malta
and Northern Ireland.
Use of antigen testing varied considerably and ranged from little or no use
in some countries to include population-wide screening (Austria, Czechia
and Slovakia), infection control and outbreak management in either general
settings and or specific settings in all but five jurisdictions (England,
Finland, Greece, Malta and Northern Ireland), and testing contacts after
identification (Austria, Denmark, France, Germany, Ireland, Italy, Portugal,
Spain, Wales and Switzerland).
There was also considerable variation between the specific criteria for
considering antigen testing and the applicable settings. Germany, Ireland,
Italy and Portugal (only for screening in education settings) limited the use
of antigen testing to situations where there was a high test positivity rate
(e.g., ≥10%) or the 7- or 14-day incidence exceeded a stated threshold for
that setting.
The use of antigen testing for screening was reported in 18 countries
although the recommended frequency of screening was only specified in six
countries.
Testing for infection control or outbreak management purposes in specific
settings was reported in 12 of the 24 countries. For eight countries, care
facilities were included, although these were specifically excluded in
Belgium, with schools specified in five countries.
Antigen tests are generally less sensitive than RT-PCR for detecting SARS-
CoV-2, and their clinical performance largely depends on the circumstances
in which they are used, performing best when viral load is highest.
Although not systematically searched for, there appears to be currently
limited evidence on the effectiveness of antigen screening to reduce the
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Health Information and Quality Authority
spread of COVID-19. The findings from three studies reporting on the
effectiveness of mass population screening in Slovakia suggest that the role
of population screening using antigen tests remains uncertain.
HIQA’s rapid health technology assessment of alternatives to laboratory-
based real-time RT-PCR published in October 2020 advises the following
issues should be considered regarding the expansion of test capacity:
identification of the goal of testing in a given setting, selection of the most
appropriate technology, taking into account the necessary resources to
establish testing in this setting, and investigation of available CE-marked
devices, with consideration to key device characteristics.
While many countries have identified a role for antigen testing for
asymptomatic individuals in community settings, the actual extent to which
it is used in asymptomatic individuals is difficult to ascertain. There is
variation in the criteria for testing, test specimens, test characteristics, the
requirements for confirmatory molecular testing and in the settings or
circumstances in which the tests may be used. These factors have
implications for the diagnostic test accuracy and the effectiveness of the
antigen testing to inform infection prevention and control measures and
prevent transmission.
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1 Background
Since the onset of the coronavirus disease 2019 (COVID-19) pandemic in early 2020,
governments across the globe have applied restrictive public health policy measures,
or non-pharmaceutical interventions, at various stages, and with different levels of
intensity, to reduce or slow down transmission of the virus.
National testing strategies have been developed to identify cases of COVID-19 in
symptomatic individuals and expanded over the course of the pandemic to identify
and isolate asymptomatic cases through preventive screening programmes. Mass
testing programmes have also been implemented to rapidly identify and isolate
cases in high-risk areas, for example, as well as across populations. To further
interrupt chains of transmission, governments, either at a national or local level,
have been tracing contacts of confirmed cases to isolate potentially infected
individuals in the community. In some situations, enhanced contact tracing
measures have been deployed to identify the index case, as well as any close
contacts. Governments have also relied on technology as a means to either identify
close contacts of a confirmed case, or to support traditional contact tracing efforts.
The Health Information and Quality Authority’s (HIQA’s) Health Technology
Assessment (HTA) Team has been requested to review the public health measures
and strategies that are being used internationally to limit the spread of COVID-19.
2 Methods
A detailed summary of the methods used for this review is provided in the protocol:
Public health measures and strategies to limit the spread of COVID-19: an
international review, available on www.hiqa.ie. Briefly, the review focuses on the
national response to COVID-19 in 17 countries that were experiencing a resurgence
in COVID-19 cases in October 2020 and which were identified by NPHET as being in
a similar phase of pandemic response as Ireland. The countries comprise 12 EU/EEA
countries (Austria, Belgium, Czechia, Denmark, France, Germany, Ireland, Italy,
Netherlands, Portugal, Spain, Sweden), the UK (England, Northern Ireland, Scotland
and Wales), and Switzerland. For the purposes of this update, the national response
to COVID-19 in Finland, Greece, Hungary, Malta, Norway, Poland and Slovakia was
also included.
A number of key epidemiological parameters are extracted as part of the review for
the purposes of describing the current epidemiological situation in each country. As
the European Centre for Disease Prevention and Control (ECDC) has moved to a
weekly reporting of COVID-19 data, up-to-date information on the epidemiological
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situation in each country was directly sourced from Our World in Data,(1) which is
produced by the Oxford Martin School at the University of Oxford and the Global
Change Data Lab (A UK-based charity in the education sector). Since the data for
the UK are aggregated, a breakdown of the epidemiological data by country is not
provided. The epidemiological parameters include the:
daily number of new cases
14-day notification rate of newly reported COVID-19 cases per 100,000
population
daily number of new deaths
14-day notification rate of newly reported COVID-19 deaths per million
population
percentage of COVID-19 tests performed weekly that are positive.
With respect to testing data, Our World in Data(1) report RT-PCR tests only, while the
ECDC(2) report both RT-PCR tests and antigen tests. Therefore the following
epidemiological parameters are also provided based on the ECDC data:
weekly number of tests conducted
testing rate per 100,000 population
percentage of COVID-19 tests performed weekly that are positive.
Information on public health measures (that is, restrictive measures or non-
pharmaceutical interventions) that are currently in place to limit the spread of
COVID-19 was sought from government resources. The public health measures of
interest include those related to:
movement of people (for example, stay at home measures or curfews)
social or mass gatherings
education
business activities
sporting activities
religious activities
travel (domestic and or international)
extended use of face coverings
special arrangements for the Christmas or end of year holiday period.
Where countries have developed detailed frameworks for living with COVID-19 at
varying levels of community transmission, for example, this information was
extracted, alongside any criteria that are being used to inform a change in public
health measures, or level of restrictions.
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Finally, details of national testing and contact tracing strategies were extracted for
each country to provide information on the extent that these measures are being
used to quickly identify and isolate cases of COVID-19.
The review was first undertaken on 24 November. Weekly updates were provided up
to 15 December, as required by the NPHET.
An update of education public health measures only was provided on 23 December
2020 and included data extracted on 22 December 2020. An update of the
epidemiological situation and education public health measures in each country as at
5 January 2021 was provided on 6 January 2021. An update on antigen testing in
asymptomatic people in community settings only was provided on 3 February 2021
with data extracted on 1 February 2021.
This report provides an update on the epidemiological situation in each country with
data extracted on 8 February 2021 and antigen testing in asymptomatic people in
community settings only with data extracted on 5 February 2021.
3 Findings
3.1 Summary epidemiological data
Table 1 presents a brief snapshot of the latest epidemiological data by country. A
large number of countries, including Ireland, have seen a considerable decrease in
the number of new coronavirus cases recorded over the previous seven days. The
14-day incidence rate of new cases per 100,000 population in Ireland currently
stands at 313. Of the included countries, the rate is highest in Portugal (1,224),
Czechia (909), and Spain (846). While the rate fell over the previous seven days in
Portugal (down 26.5%) and Spain (18.6%), the 14-day incidence rate increased in
Czechia (up 2.0%). The rate also increased over the previous seven days in Finland
(4.4% [to 93.8 / 100,000 population]), Greece (41.9% [116.7]), Hungary (7.7%
[178.4]), and Slovakia (4.2% [495.6]), while in all other countries, the 14-day
incidence rate declined, reflecting the downward trend in the number of new cases
recorded in each country.
Despite declines in the 14-day incidence rate, the recent surge in cases continues to
impact on the death rate in most countries. The 14-day death rate per million
population in Ireland currently stands at 144.8. It is surpassed only by Czechia
(175.6 per million population), Portugal (356.3), Slovakia (220.3), and the UK
(210.5).
With respect to testing data, Our World in Data(1) report RT-PCR tests only, while the
ECDC(2) reports both RT-PCR tests and antigen tests. Therefore both sets of testing
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data are reported separately in Table 1 and Table 2, respectively. Based on ECDC
data (including both RT-PCR and antigen tests), weekly testing per 100,000
population currently ranges from 742 in Poland to 13,409 in Denmark, with Ireland
at 2,795 per 100,000. In a number of countries, the positivity rate (that is, the share
of tests that are returned as positive over the previous seven days) is trending
downwards. However, the positivity rate has increased in Austria (up 58.3% [to
1.4% positivity]), Finland (15.9% [2.7% positivity]), Greece (23.9% [2.4%
positivity]), Malta (7.9% [to 5.2% positivity]), the Netherlands (5.6% [10.9%
positivity]), Portugal (73.7% [to 20.3% positivity]) and Slovakia (13.5% [19%
positivity]). It is important to note that the data are not up-to-date; the latest data
from the ECDC were published on 05 February 2021 and reflect activity and test
positivity for the final week of January. In addition, it is important to note that cross-
country comparisons of the positivity rate are difficult due to changes in testing
criteria over time.
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Table 1 Summary epidemiological data on 08 February 2021 (Source: Our World in Data(1))
Country Daily number of 14-day notification of Daily number of 14-day notification Daily share of tests
new cases (weekly new cases / 100,000 new deaths (weekly of deaths / million returned as positive*
% change) population (weekly % change) population (weekly (weekly % change)
% change) % change) [04-Feb-21]
Austria 1,057 (-6.0%) 212.9 (-6.9%) 20 (-64.9%) 64.5 (-11.4%) No data
Belgium 873 (-30.9%) 272.9 (-0.1%) 34 (6.3%) 52.5 (-6.6%) 5.4 (-1.8%)
Czechia 2,430 (-4.9%) 909.5 (2.0%) 98 (16.7%) 175.6 (-3.2%) 13.2 (-5.7%)
Denmark 430 (-11.9%) 116.7 (-25.5%) 0 (-100.0%) 35.6 (-39.4%) 0.5 (-16.7%)
Finland 353 (44.7%) 93.8 (4.4%) 0 (-100.0%) 6.0 (-44.1%) 2.9 (20.8%)
France 4,343 (-1.0%) 435.0 (-1.2%) 460 (0.9%) 90.9 (1.8%) 6.5 (-4.4%)
Germany 4,650 (-30.3%) 169.1 (-18.1%) 483 (-46.1%) 108.2 (-16.0%) 8.5 (-14.1%) [31-Jan-21]
Greece 629 (16.9%) 116.7 (41.9%) 25 (-24.2%) 31.3 (-4.4%) 2.8 (27.3%)
Hungary 1,160 (3.2%) 178.4 (7.7%) 65 (20.4%) 117.1 (-3.3%) 7.6 (-5.0%)
Ireland 829 (-17.6%) 313.4 (-31.9%) 6 (-40.0%) 144.8 (2.0%) 5.4 (-34.9%)
Italy 7,969 (0.6%) 280.1 (-0.9%) 307 (-6.7%) 94.3 (-9.4%) 4.8 (-5.9%)
Malta 137 (10.5%) 442.1 (-14.6%) 0 (-100.0%) 65.7 (3.6%) No data
Netherlands 2,246 (-30.4%) 325.5 (-14.4%) 27 (0.0%) 50.0 (-12.4%) 10.9 (5.8%) [31-Jan-21]
Norway 346 (16.9%) 70.1 (-10.1%) 0 (-100%) 6.3 (-26.1%) 1.7 (-5.6%) [03-Feb-21]
Poland 2,431 (-2.9%) 197.0 (-3.1%) 45 (7.1%) 98.6 (-2.2%) 13.5 (-4.9%)
Portugal 2,505 (-56.8%) 1,224.0 (-26.5%) 196 (-28.7%) 356.3 (-2.6%) 18.1 (-10.0%)
Slovakia 757 (70.5%) 495.6 (4.2%) 72 (4.3%) 220.3 (1.5%) 20.4 (44.7%)
Spain 47,095 (-40.9%) 846.3 (-18.6%) 909 (19.3%) 130.2 (14.6%) 14.1 (-6.0%) [28-Jan-21]
Sweden† 3,388 (41.2%) 404.9 (-5.9%) 87 (22.5%) 109.9 (-12.5%) 10 (-16.0%) [31-Jan-21]
UK 14,138 (-24.3%) 429.0 (-27.8%) 333 (-18.2%) 210.5 (-14.6%) 3.2 (-31.9%)
Switzerland 3,280 (-13.1%) 249.0 (-14.3%) 38 (-46.5%) 58.4 (-23.5%) 8.3 (-6.7%)
*Calculated as 7-day rolling average of daily cases, divided by the 7-day rolling average of daily tests (RT-PCR tests only)
† Latest available data on the number of new cases and deaths are for 05-Feb-21
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Table 2 Summary international testing data for week four, 2021 [published 05-Feb-21]* (Source: ECDC(2))
Country Number of tests Testing rate per 100,000 population Weekly % test positivity
conducted (weekly % change) (weekly % change)
Austria 655,713 7,401.8 (-42.7%) 1.4 (58.3%)
Belgium 345,046 3,012.1 (11.8%) 4.8 (-3.2%)
Czechia 344,053 3,230.6 (6.7%) 13.8 (-7.9%)
Denmark 778,547 13,409.2 (4.3%) 0.5 (-34.9%)
Finland 105,759 1,916.6 (11.6%) 2.7 (15.9%)
France 2,122,366 3,167.1 (7.7%) 6.8 (-6.6%)
Germany 1,070,000 1,288.9 (0.2%) 7.5 (-20.6%)
Greece 209,772 1,956.0 (19.1%) 2.4 (23.9%)
Hungary 109,018 1,115.5 (10.7%) 7.6 (-2.9%)
Ireland 137,066 2,794.8 (-6.4%) 6.6 (-35.2%)
Italy 1,732,691 2,870.6 (14.7%) 5.0 (-12.1%)
Malta 22,620 4,583.0 (-2.5%) 5.2 (7.9%)
Netherlands 262,630 1,519.7 (-23.7%) 10.9 (5.6%)
Norway 153,361 2,878.3 (8.6%) 1.2 (-28.7%)
Poland 281,620 741.6 (-1.0%) 12.5 (-9.2%)
Portugal 410,589 3,995.4 (-44.7%) 20.3 (73.7%)
Slovakia 67,850 1,244.9 (-10.2%) 19.0 (13.5%)
Spain 1,743,885 3,715.4 (1.3%) 13.2 (-11.9%)
Sweden† 193,188 1,888.4 (-3.8%) 10.7 (-11.1%)
* Testing data for the UK and Switzerland are not routinely captured by the ECDC (includes RT-PCR and antigen tests)
† Latest data are for week three, 2021
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3.2 Antigen testing in asymptomatic individuals in
community settings
Of the 24 jurisdictions included in this review, 22 reported use of antigen testing in
asymptomatic individuals in community settings. The two exceptions were Malta and
Northern Ireland; use in Finland is limited to testing inbound travellers, although RT-
PCR remains the most common testing method. In many countries antigen testing
for asymptomatic persons in the community is advised for consideration in the
context of screening, outbreak management and testing of contacts after
identification. However, there is considerable variation in the criteria for testing, in
the requirements for confirmatory testing and in the settings or circumstances in
which the tests may be used (from little or no use in some countries to use in a
range of settings in others).
The information is summarised by setting below and in Table 3 which includes
criteria for testing, context and setting in each country. Full details of testing in all
countries are provided in Appendix Table 1.
General settings
In Belgium, antigen testing of asymptomatic people is only proposed as part of a
cluster investigation in group settings with a low-risk profile, such as schools,
businesses, sports clubs and special youth care, but not in care facilities. In
Denmark, testing may be considered for select groups (including specific age
groups) or in areas where prevalence is particularly high and there is widespread
spread of infection. In France, testing may be used for collective screening organised
by a public authority or an employer in the event of a suspected cluster or
particularly active circulation of the virus. Testing in Italy may be recommended in
the context of a high positivity rate for example ≥10% and includes community
screening for public health reasons. Testing may also be considered as part of
outbreak management in work places and other institutions in the Netherlands.
Similarly in Czechia, Norway and Poland, testing may be considered in the event of
an infection outbreak. Positive results in Czechia and Norway should be confirmed by
a RT-PCR test. While RT-PCR tests are preferred, in Spain antigen testing may be
considered for population subgroup epidemiological studies with a positive result
requiring a follow-up RT-PCR test. In Switzerland, it may be considered as part of
large-scale outbreak prevention, for example in schools, ski areas and certain
regions and as part of precautionary measures in screening attendees at a sporting
event or concert and screening employees at the request of an employer.
Voluntary population-wide antigen testing is being carried out in both Austria and
Czechia with a positive result requiring a follow-up RT-PCR test. Free random sample
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testing for citizens commenced in Greece in December 2020 as part of its strategy to
protect citizens and break the chains of transmission. Slovakia has conducted two
rounds of national mass screening to date using antigen tests, with a number of
follow up rounds in areas with high positivity in previous rounds. A number of
community testing pilots are due to commence in targeted communities with high
prevalence across the UK.
Residential and long-term care facilities
In Germany, antigen testing in care facilities is considered for asymptomatic staff,
patients and visitors in the context of screening in geographical areas with increased
incidence of infection and for infection control purposes in facilities where RT-PCR
capacity is limited or for an immediate decision to initiate cohort isolation. Positive
results require a follow-up RT-PCR test. In Italy and Switzerland, it may also be
considered for periodic screening in facilities in areas where there is high community
transmission. Although RT-PCR is preferred, in Spain antigen testing is considered
for screening of staff and both existing and new residents, with all positive results
followed up with a RT-PCR test. Similarly in Sweden it may be considered for
screening new and returning residents and weekly screening of staff in special
housing for the elderly. In Czechia, England and Scotland, staff and visitors at
residential care facilities may be screened (using lateral flow tests in England and
Scotland), while staff may be considered for weekly or fortnightly testing in Wales.
Positive test results in Czechia and Scotland require a follow-up RT-PCR test.
In the Netherlands, testing may be considered as part of outbreak management
within a facility and a negative result should be confirmed by a RT-PCR test. In the
event of a high spread of infection in the local community, staff and residents in care
facilities in Norway may undergo regular testing with positive results followed up
with a RT-PCR test. In Portugal, Scotland and Sweden, antigen testing may also be
considered as part of outbreak management. In Switzerland it may be considered as
a precautionary measure for visitors to care homes, in which case the visitor will be
invited for a test by the establishment. In Hungary and Spain, asymptomatic close
contacts in long-term care institutions can be considered for testing and a RT-PCR
test is mandatory following a negative test result.
Other health care settings outside the hospital or acute setting
In England, antigen testing (using lateral flow tests) is offered to patient-facing staff
delivering NHS services in primary care across all four primary care contractor
groups (Medical, Dental, Optometry, and Community Pharmacy) and includes staff at
vaccination sites.
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Contacts
Asymptomatic contacts may avail of an antigen test in France. In Germany however,
antigen testing of asymptomatic contacts should only be considered in exceptional
circumstances, such as in the case of limited RT-PCR capacity or in urgent cases to
bridge the waiting time for the result of a simultaneously initiated RT-PCR test.
Similarly, in Ireland, testing of asymptomatic close contacts can be considered as
part of the response to a notification of a potential outbreak in the community or in
the early stages of management of a confirmed outbreak, but only if there is (i)
evidence of widespread community transmission (>10% positivity in the local
community), (ii) there are symptomatic person(s) on site and (iii) the outbreak
involves a vulnerable population, including among staff and or residents of long-term
care facilities, homeless hostels, residents of direct provision centres and prisons. If
a “not detected” test result is obtained in the close contact, the test should be
repeated using RT-PCR. Asymptomatic contacts with high risk exposure in Italy
should only be tested with antigen tests in areas where the positivity rate is ≥10%.
In Denmark, it may be considered when people are notified via the Danish COVID
App that they have been in contact with a confirmed case and for screening non-
close contacts in cases of infection within work places with large offices. In Portugal,
antigen testing may be offered to high risk contacts if RT-PCR testing is not
available, or the result is not available in less than 24 hours; however RT-PCR
confirmation of positive antigen tests is only required for those deemed close
contacts. Although RT-PCR is preferred, in Spain antigen testing can used in the
case of asymptomatic close contacts cohabiting or in outbreaks and where the speed
of the response time helps the rapid handling of contacts. A positive result requires a
follow-up RT-PCR test. In Switzerland, it may also be considered in the case of
notification from the SwissCovid App that someone has been in contact with a
confirmed case.
Education
If there is a confirmed case in schools or day care facilities in Germany, rapid
antigen tests can be sought from pharmacies. The respective group, usually the
class, should quarantine for five days. A rapid test should follow on day five and
children who test negative can then return to school. In Hungary, weekly testing of
teachers and staff of nurseries and kindergartens commenced in November. In
Portugal, screening in schools and education establishments is generally considered
as part of outbreak management and or when the region’s 14-day cumulative
incidence is more than 960 per 100,000 inhabitants. Similarly in Belgium, the
Netherlands and Wales, testing is considered as part of outbreak management. In
England, screening can be considered in schools using lateral flow tests. In both
England and Scotland there is voluntary screening in universities, while returning
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university students in Wales can be offered testing for participation in onsite
activities, all using lateral flow tests. In Scotland, a positive result must be followed
up with a RT-PCR test. Under a phased approach that commenced in January 2021,
voluntary testing, using lateral flow tests, will be made available to all members of
staff and all pupils and students in schools, special schools and colleges in Wales. In
schools and colleges, there will be daily testing for those identified as close contacts
(outside their household) of confirmed cases. In special schools, there will be weekly
testing.
Travel
Antigen testing of asymptomatic inbound travellers may be considered in Finland
(RT-PCR preferred), the Netherlands and Norway.
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Table 3 Summary of antigen testing in asymptomatic individuals in community settings (extracted 5 February 2021)
Criteria Purpose Follow-up Other
testing
Purpose Screening Infection control/ Testing contacts
Outbreak management
Setting General Care/Other General Care/Other General Care/Other
Austria(3-5) - Mass screening. In facilities with No detail. - No detail. - Positive -
exposed results
personnel or requires a
those at high PCR test.
risk of serious
illness.
Belgium(6, 7) - - - - Low risk settings - - -
with cluster, e.g.
schools,
businesses,
sports clubs &
special youth
care.
Czechia(8, 9) - Mass screening. Visitors and staff No detail. - - - Positive -
in LTCFs. result
requires a
PCR test.
Denmark(10, - Gradual Gradual Only select - Close contact Non close - -
11) implementation implementation groups, e.g. if notified via contacts in
across settings. across settings. 15-25yrs. App. large work
places.
Finland(12, 13) - - - - - - - - PCR test
primarily
used to test
at border but
antigen test
also used.
France(14) - No detail. No detail. No detail. No detail. No detail. No detail. -
Page 18 of 44Public health measures and strategies to limit the spread of COVID-19: antigen testing
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Criteria Purpose Follow-up Other
testing
Purpose Screening Infection control/ Testing contacts
Outbreak management
Setting General Care/Other General Care/Other General Care/Other
Germany(15, 7-day - Staff, patients (if - Facilities with Exceptional Exceptional Positive -
16) incidence > PCR not confirmed circumstance circumstance result
50/100,000 available before infection - only if e.g. limited e.g. limited requires a
population. (re) admission) PCR capacity PCR capacity PCR capacity PCR test.
and visitors to limited/need to or in urgent or where
health care urgently initiate cases before need to
facilities without cohort isolation. confirmation urgently
a COVID case. Schools & day of PCR test. isolate.
care following
confirmed case
in a class
(criterion re 7-
day incidence
doesn’t apply).
Greece(17, 18) - Random - - - - - -
sampling of -
registered
citizens.
Hungary(19, - - Weekly - LTCFs. - Close contact Negative -
20) (voluntary) staff and tests in
testing of social residents in LTCFs
care workers, LTCFs. confirmed
teachers & by PCR.
nursery staff.
Page 19 of 44Public health measures and strategies to limit the spread of COVID-19: antigen testing
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Criteria Purpose Follow-up Other
testing
Purpose Screening Infection control/ Testing contacts
Outbreak management
Setting General Care/Other General Care/Other General Care/Other
Ireland(21) >10% - - - LTCFs, homeless - Close If test is -
positivity rate hostels, contacts of ‘not
in local residents of staff/resident detected’,
community direct provision s in LTCFs, PCR test
And centres, prisons, homeless required.
Symptomatic Irish Travellers hostels,
person on site. etc. residents of
And direct
Outbreak provision
involves centres,
specific prisons, Irish
settings/ Travellers
groups. etc.
Italy(22) High positivity Community Periodic - RCFs and LTCFs Contacts - - -
rate e.g. screening for screening of where rapid with high
≥10% public health residents/staff/ action required. risk
reasons. visitors in exposure.
prisons and
migrant
reception
centres.
Malta(23) - - - - - - - - -
Netherlands( - Confirm validity - - RCFs. - - A negative Travellers
24, 25) of negative PCR Schools. result returning
test in order to Workplaces. should be from high
attend events. confirmed risk areas.
(not currently by PCR in
applicable). RCFs.
Poland(26) - - - No detail. - - - - -
Page 20 of 44Public health measures and strategies to limit the spread of COVID-19: antigen testing
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Criteria Purpose Follow-up Other
testing
Purpose Screening Infection control/ Testing contacts
Outbreak management
Setting General Care/Other General Care/Other General Care/Other
Portugal(27, - - Students & staff - LTCFs. - High-risk Positive For
28) in education Schools and contacts if results for admission to
settings in areas educational PCR not close facilities
with a 14-day establishments. available/ contacts of when PCR
cumulative test result confirmed unavailable
incidence > not available case (e.g. children
960/100,000 inPublic health measures and strategies to limit the spread of COVID-19: antigen testing
Health Information and Quality Authority
Criteria Purpose Follow-up Other
testing
Purpose Screening Infection control/ Testing contacts
Outbreak management
Setting General Care/Other General Care/Other General Care/Other
England(33, - Staff and visitors - - - - - -
34) at RCFs.
Patient-facing
NHS primary
care staff.
Universities &
schools.
Northern - - - - - - - - -
Ireland(35)
Scotland(36- - - Staff (twice Pilots in targeted Staff at RCFs. - - Positive -
38) weekly) & communities results
visitors at RCFs. with high require a
Universities prevalence. PCR test.
(voluntary).
Wales(39-41) - - Staff at RCFs - Schools. - Schools: - -
(weekly/ close contact
fortnightly). (outside
Universities – household)
returning of confirmed
students & for case.
onsite activities).
Staff & students
in special
schools
(weekly).
Norway(42) In the event of - Regular testing No detail. - - - Positive Border
a high spread of employee and result testing.
of infection in residents in care followed by Positive must
the local facilities. PCR test. be PCR
community. confirmed.
Page 22 of 44Public health measures and strategies to limit the spread of COVID-19: antigen testing
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Criteria Purpose Follow-up Other
testing
Purpose Screening Infection control/ Testing contacts
Outbreak management
Setting General Care/Other General Care/Other General Care/Other
Switzerland(4 - - Precautionary Regions. Schools. Notification - In certain -
3) measures: Ski-areas. on App/by situations a
Visitors to doctor. positive
LTCFs/RCFs. result
Attendees at requires a
sporting events, PCR test.
concerts.
Requested by
employer.
Page 23 of 44Public health measures and strategies to limit the spread of COVID-19: antigen testing
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4 Discussion
The role of antigen testing for SARS-CoV-2 detection in asymptomatic individuals in
community settings varies considerably between the 24 countries reviewed. There is
variation in the criteria for testing, in the requirements for confirmatory molecular
testing and in the settings or circumstances in which the tests may be used (from
little or no use in some countries to use in a range of settings in others). Uses
include population-wide screening, infection control and outbreak management, and
testing contacts after identification. Although not specified in the majority of
documents reviewed, the antigen testing considered within these reports likely refers
to the use of rapid antigen tests (lateral flow assays) in the context of near patient
testing (NPT). This is distinct from laboratory-based antigen testing; companies
report that a number of laboratory-based antigen tests which can be run on existing
immunochemistry analysers will be commercially available in early 2021.
While guidance on the use antigen testing is quite broad in a number of countries,
the actual extent to which antigen testing is being undertaken, and specifically the
extent to which antigen testing is used in asymptomatic individuals is difficult to
ascertain. For example, data have been reported on the numbers screened under
the population-wide screening programme in Slovakia, but specific data on the
numbers of asymptomatic individuals that were screened are not reported. Similarly,
while individual countries may report disaggregated data on the number of antigen
and RT-PCR tests conducted, data are not available on the number of antigen tests
undertaken in asymptomatic individuals.
In the EU/EEA countries included in this review, for the time period (week 4, 2021)
there was an apparent 18-fold difference in the total (RT-PCR plus antigen) SARS-
CoV-2 test rate between countries ranging from 741.6 per 100,000 in Poland to
13,409.2 per 100,000 in Denmark; the test rate for Ireland (2,794.8 per 100,000)
that week was at the median rate for the countries reviewed (2,870.6 per 100,000).
However, as noted, both the ECDC and Our World in Data advise caution in
comparing testing rates between countries due to heterogeneity in reporting
practices relating to the unit of measurement (for example, number of people
tested, cases tested, tests performed etc.), whether pending results are included
and the time period covered.
Antigen tests are generally less sensitive than RT-PCR for detecting SARS-CoV-2.
Their clinical performance largely depends on the circumstances in which they are
used, generally performing best when viral load is highest.(44) The test accuracy
depends on a number of factors including the time from infection onset, the
concentration of virus in the specimen, the quality and processing of the specimen
collected, and the precise formulation of the reagents in the test kits.(45) The specific
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setting in which they are deployed and likely impact on RT-PCR test capacity are also
relevant considerations in their deployment. In a high prevalence setting, antigen
testing will have a high positive predictive value with a positive value likely to
indicate true infection.(46) In such settings, and where RT-PCR capacity is limited or
where urgent identification of potentially positive cases is required, such as in
settings with medically vulnerable individuals, antigen testing in asymptomatic
individuals may have a role to play in an overall testing strategy. However, a
negative result in such a setting may require a confirmatory RT-PCR test, particularly
for those with a known history of exposure. Our current review identified that
Germany, Ireland, Italy, and Portugal (only for screening in education settings) limit
the use of antigen testing to situations where there is a high test positivity rate (e.g.,
≥10%) or the 7- or 14-day incidence exceeds a stated threshold for that setting.
The guidance from Germany goes further in only recommending antigen testing in
the event of limited RT-PCR test capacity and or if rapid cohort isolation is required.
In low prevalence settings, a rapid antigen test will have a high negative predictive
value, but a low positive predictive value.(46) If used correctly, a rapid antigen test
should be able to rule out a highly infectious case in such a setting. However, if
deployed on a large scale in such settings, a large proportion of positive results will
be false positives. For example, at a prevalence of 50/100,000 and a test sensitivity
and specificity of 0.8 and 0.98 respectively, of 2,039 positive results, 40 (0.2%)
would be true positives and 1,999 (98%) would be false positive results.(46) The
requirement for confirmatory RT-PCR testing of these positive results could
potentially impact on overall RT-PCR test capacity and the overall efficiency and
cost-effectiveness of the testing programme.
With regard to test performance, the WHO recommends a minimum sensitivity of
80% and a minimum specificity ≥97%, but ideally greatly than 99%.(45) However,
there is considerable variation between commercially available tests and the WHO
report available independent data demonstrating sensitivity ranging from 0% to
94%; specificity data are more consistent between tests, typically exceeding
97%.(45) Therefore, the clinical performance of the test should be evaluated for the
intended use and conditions, including the specific target population (including
symptomatic and or asymptomatic). While multiple studies have reported rapid
antigen test sensitivity rates exceeding 80% in symptomatic individuals with
suspected COVID-19 tested shortly after symptom onset, sensitivity is substantially
lower among asymptomatic individuals.(47-49) Studies report a correlation between
test sensitivity and cycle threshold (Ct values) with improved sensitivity at lower Ct
values. While Ct values cannot be used to determine viral load or infectivity of an
individual, on a population level, it is noted that there is an inverse relationship
between Ct value and the amount of genetic material present in the sample.(47-49)
Therefore, it has been argued that antigen tests have a role in identifying individuals
most likely to be infectious to others. However, given reports of false negative
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results in individuals despite high viral loads, there remains a risk of missed
diagnoses that could have a substantial impact from a public health point of view.
A rapid search was conducted to identify literature reporting on the effectiveness of
the strategies adopted by the countries included in this review. Three studies (two
preprints) were identified that reported on the effectiveness of the population-wide
screening in Slovakia. Pavelka et al. report the results of the mass screening,(50)
concluding that a combination of restrictions on movement and two rounds of large
scale rapid antigen testing contributed substantially to achieve reductions in
prevalence of over 50% within a week. They also acknowledge that quarantining of
household contacts was a crucial contribution to the effectiveness of mass testing.
However, in response, Černák criticised this study and reports that the authors refer
to conclusions that are not supported by experimental data.(51) He argues that the
authors failed to consider many fundamental phenomena in their proposed computer
simulations and data analysis, in particular the complexity of SARS-CoV-2 virus
spread. Lastly, Frnda and Durica provide an overview of the first and second rounds
of testing analysing the results using mathematical simulations.(52) They report that
their results have proven that screening can substantially reduce the number of daily
reported new cases in areas with high prevalence, but the benefits of such testing
are questionable in regions with low prevalence of COVID-19. In response to the
reported results of population wide testing in Slovakia, it was also highlighted that a
suggestion of effectiveness of mass screening in one place, is not straightforward to
interpret as suggesting that it will work everywhere.(53) Additionally, a number of
recently published articles in academic journals highlight the ongoing debate
concerning whether or not the use of antigen tests can help to control the spread of
SARS-CoV-2.(53-55) While many countries have identified a role for antigen testing for
asymptomatic individuals in community settings, the actual extent to which it is used
in asymptomatic individuals is difficult to ascertain. There is variation in the criteria
for testing, test specimens, test characteristics, the requirements for confirmatory
molecular testing and in the settings or circumstances in which the tests may be
used. These factors have implications for the diagnostic test accuracy and the
effectiveness of the antigen testing to inform infection prevention and control
measures and prevent transmission.
The need for a robust ethical framework to guide mass testing of COVID-19 in
asymptomatic individuals has been highlighted in the UK. It is argued that the
development of such a framework, based on stakeholder engagement and ethical
analysis, would enable systematic and principled decision making, helping to assure
the ethical standing of mass testing programmes for COVID-19.(56)
The European Centre for Disease Prevention and Control (ECDC) published a report
in November 2020 detailing scenarios and settings during which it is appropriate to
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use rapid antigen tests. At that point in time, they reported that most rapid antigen
tests available on the market were developed for testing in symptomatic persons and
were not currently recommended for use in asymptomatic persons.(46) However, the
World Health Organization (WHO) published a report on 21 December 2020 advising
that testing of asymptomatic contacts of cases may be considered even if the
antigen test is not specifically authorised for this use as asymptomatic cases have
viral loads similar to symptomatic cases. However, the WHO recommend that a
negative result is not sufficient to remove a contact from quarantine
requirements.(45)
HIQA’s rapid health technology assessment of alternatives to laboratory-based real-
time RT-PCR published in October 2020, identified a number of issues to consider
with regard to the expansion of test capacity:(57)
identification of the goal of testing in a given setting
selection of the most appropriate technology
taking into account the necessary resources to establish testing in this setting
investigation of available CE-marked devices, with consideration to key device
characteristics.
From an operational and resource perspective there are a number of important
considerations. The WHO advise the following critical elements that are required for
the safe and effective implementation of antigen testing:(45)
integrating an antigen testing strategy into the national response plan
procurement of the right tests and associated requirements
supply chain management and logistics
training and supervision
quality assurance
data management and connectivity
monitoring and evaluation
communication and community engagement.
The distinction between laboratory-based testing, where tests are processed by
trained laboratory personnel and near patient testing where tests are processed
outside a laboratory setting (and potentially outside a healthcare setting) is
important. As noted, it is assumed that to date, the antigen testing referred to in
international guidance documents relates to near patient testing (NPT) and use of
lateral flow antigen tests, also known as rapid antigen detection tests (RADTs).
There are important considerations in relation to the clinical and quality governance
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over any NPT testing programme, including the requirement for quality management
systems, so to be assured of the performance of antigen test analysis on site. A
number of European countries have comprehensive NPT programmes for other
conditions, so there may have been the potential to leverage existing quality
management systems and to deploy staff that have been trained in NPT. The use of
NPT in community-based settings in Ireland is very limited, so deployment of rapid
antigen testing for SARS-COV-2 would have substantial resource considerations
including the requirement for appropriately trained staff onsite to process the tests.
While rapid antigen tests can provide a test result within 12 to 15 minutes, tests
must be processed individually, with very limited potential for efficiency. Testing a
large cohort of individuals is therefore time-consuming and has significant staffing
implications.
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